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Practice Analysisof Certified Pedorthists

American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.

Certified Pedorthist Practice Analysis Task ForceDan Ballard, C.Ped.

John M. Brest, CO, C.Ped.Donald E. Cooper, C.Ped.

Dennis W. Dillard, C.Ped., RTOJohn P. Galbraith, C.Ped.

Darlene Hall, C.Ped.M. Edward Hicks, Jr., CO, C.Ped.

Louis N. Iannuzzi, C.Ped.Wayne R. Rosen, CPO, C.Ped.

Steven R. Whiteside, CO, FAAOP

American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.

Catherine A. Carter, Executive Director

Professional Examination ServiceSandra Greenberg, Ph.D.Alexander Demos, M.S.

© 2009 by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. All rights reserved. No part of this document may be reproduced in any form without written permission of the American Board for Certification in Orthotics,

Prosthetics and Pedorthics, Inc., 330 John Carlyle Street, Suite 210, Alexandria, VA 22314.

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PRACTICE ANALYSIS OF CERTIFIED PEDORTHISTS

Table of Contents

Acknowledgements .......................................................................................................................... v

Introduction .................................................................................................................................... vi

Executive Summary of the Study Process ....................................................................................... vii

Section 1

Results Related to Professional Background, Work Setting

and Demographic Information ................................................................................................. 1

Section 2

Results Related to the Domains ................................................................................................ 9

Results Related to the Tasks .................................................................................................... 11

Results Related to the Knowledge and Skills ........................................................................... 16

Section 3

Results Related to Pedorthic Devices ...................................................................................... 20

Highlights and Qualitative Comments ................................................................................... 24

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Table of Tables

Table 1. Current ABC Credential(s) ................................................................................................1

Table 2. All Current ABC Credential(s) Held ...................................................................................1

Table 3. Year Credentialed in Pedorthics ..........................................................................................2

Table 4. Years of Experience in Pedorthic Practice ............................................................................2

Table 5. Highest Educational Degree/Certificate/Diploma Earned in Any Discipline .......................3

Table 6. Additional Healthcare Professional Licenses and/or Certifications Held ...............................3

Table 7. Primary Work Setting ..........................................................................................................4

Table 8. Total Number of Pedorthic Employees Located at Primary Work Setting ............................4

Table 9. Percentage of Work Time Devoted to Each of the Following Areas .....................................5

Table 10. Percentage of Direct Patient Care That Occurred in Various Settings ...................................5

Table 11. Percentage of Patients in Following Age Ranges ...................................................................5

Table 12. Percentage of Patients in Each of the Following Primary Diagnostic Categories ...................6

Table 13. Percentage of Diabetic Patients the Following Primary Diagnostic Categories ......................6

Table 14. Percentage of Diabetic Patients that had Significant Peripheral Neuropathy .........................6

Table 15. Gender of Respondents .......................................................................................................7

Table 16. Age of Respondents .............................................................................................................7

Table 17. Racial/Ethnic Background of Respondents ........................................................................7

Table 18. Domains and Tasks in the Practice Analysis Survey of Certified Pedorthists .........................8

Table 19. Descriptive Statistics for Domains, Mean for Frequency and Criticality .............................10

Table 20. Task Statements Mean for Frequency and Criticality .........................................................12

Table 21. Knowledge and Skill Statements ........................................................................................16

Table 22. Practice Areas ....................................................................................................................21

Table 23. Breakdown of Activities Performed by Certified Pedorthists Within Each Device Type ......22

Table 24. Percentage of Custom Foot Orthoses by Category .............................................................23

Table 25. Percentage of the Custom Pedorthic Devices Incorporating (CAD/CAM) .........................23

Table 26. Percentage of All Custom Foot Orthoses Fabricated Onsite or Outsourced ........................23

Table 27. Percentage of All Custom AFO’s Fabricated Onsite or Outsourced ...................................23

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Acknowledgements

On behalf of the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc., (ABC) I am pleased to present this Practice Analysis of the Certified Pedorthist. This report describes the contemporary practice of ABC Certified Pedorthists. The respondents to the survey have provided a great service to the profession. It is imperative that as professionals and providers of patient care that certified pedorthists recognize the importance of studies such as this that provide vital information to standard setting organizations.

A project of this magnitude depends on the hard work and commitment of many professionals, and I am pleased to acknowledge their contributions. We are indebted to the ten-member ABC Practice Analysis Task Force for the wisdom and direction it provided. Its members--Dan Ballard, C.Ped., John M. Brest, CO, C.Ped., Donald E. Cooper, C.Ped., Dennis W. Dillard, C.Ped., RTO, John P. Galbraith, C.Ped., Darlene Hall, C.Ped., M. Edward Hicks, Jr., CO, C.Ped., Louis N. Iannuzzi, C.Ped., Wayne R. Rosen, CPO, C.Ped., and Steven R. Whiteside, CO, FAAOP--worked diligently to provide conceptual guidance regarding the conduct of the study and insight into the profession.

This project represents a substantial investment of ABC’s financial resources and personnel as related to ABC’s efforts in continuing to develop exemplary examination programs as well as providing information to primary and continuing education programs. It represents the culmination of a year of planning, execution, data analyses and writing. I am grateful to Catherine A. Carter, Executive Director of ABC for serving as the liaison between the task force and the staff at Professional Examination Service. She provided thoughtful and consistent support for the study and developed a highly effective communications program regarding the conduct of the study.

Robert S. Lin, CPO, FAAOPPresident

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Introduction

The American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. (ABC), contracted with Professional Examination Service (PES) to develop and implement a practice analysis and validation study for ABC Certified Pedorthists. To accomplish the objectives of the study, PES worked with a Certified Pedorthist Practice Analysis Task Force and ABC’s Executive Director over the course of a one-year project.

The former Board for Certification in Pedorthics (BCP) performed practice analysis and validation studies in 2001. The profession was resurveyed in 2008 in order to identify changes in the profession related to the delivery of care, the components available and the technology in use today.

The use of electronic delivery and data collection made the current study easier to design and implement. The use of electronic systems instead of paper and pencil allowed for a larger participant sample, gave us greater flexibility and made it easier for the respondent to participate.

Why do a practice analysis study? The goal of the practice analysis is to determine current trends in patient care, technology and practice management in the provision of pedorthic services by ABC certified pedorthists.

Why do a validation study? The goal of the validation study was to identify priorities unique in the delivery of pedorthic patient care, e.g., What highly critical tasks are performed by all certified pedorthists? What subset of knowledge and skills is essential at the time of initial credentialing? Which procedures are most frequently implemented?

What will ABC do with the results of the study?The results will be used to generate defensible credentialing test specifications designed for entry-level pedorthists. The results will also be used to identify specific topics for in-service and/or continuing education, and to provide guidance for educational program enhancement in regard to curriculum review and/or programmatic self-assessment.

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Executive Summary

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The specific objectives of the study were to:

• ConductapracticeanalysisofCertifiedPedorthistsbydelineatingandvalidatingthedomainsofpractice,the specific tasks performed, and the associated knowledge and skills required to perform each task;

• Quantifytimespentandtasksperformedwithregardtovariouspedorthicandorthoticdevices;

• Describe—intermsofageandetiology—thepatientstowhomCertifiedPedorthistsprovidedirectpatient care; and

• Developdefensibletestspecificationsinconnectionwiththemultiple-choiceexaminationforCertifiedPedorthists.

PES completed the following steps in collaboration with the Certified Pedorthist Practice Analysis Task Force:

• Conducted one meeting of the task force

• Revised the delineation

• Developedanonlinesurveyofpractice,theSurveyfortheAmericanBoardforCertificationinPedorthics. Note: the survey comprised two versions, including alternate forms of Section 3, as described below:

Introduction, including a description of the purpose of the survey and instructions for completing and returning the survey.

Section 1: Professional and Demographic Questions, including questions about the respondent’s credentials, educational and professional background, work setting, supervisory responsibilities, patient base, and demographic characteristics.

Section 2: Device Lists and Practice Questions, including activities performed in connection with pedorthic and orthotic devices, and time spent in various practice areas.

Section 3: Tasks, including 56 tasks delineated in association with six domains of practice. or Section 3: Knowledge and Skills, including 87 knowledge and skills statements delineated in

association with six domains of practice.

Section 4: Domains, including six domains of practice.

Section 5: Qualitative questions, including open-ended questions regarding knowledge and skills recently acquired, and the benefits of ABC certification.

• Analyzed the data, developed a description of practice and developed empirically derived test specifications.

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Survey Return Rate

The overall survey return rate was 36%. The return rate was derived by taking the number of

completed surveys received and dividing it by the number of surveys that were eligible to be completed.

The number eligible was defined as the total number of surveys mailed, minus those that were not

deliverable. Approximately 2000 Certified Pedorthists were sampled and 699 completed the entire

survey, for an overall return rate of 36%––very acceptable when compared with studies of other

professions wherein potential respondents were required to respond to a detailed and comprehensive

survey such as that used in the present study.

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Results Related to Professional Background, Work Setting Information, and Demographic Information

This section provides background information regarding the sample of ABC Certified Pedorthists. The survey included a questionnaire regarding professional history and the respondent’s work environment, educational background, and demographic information.

As documented in Table 1, respondents held one or more ABC-related credentials. While about 80% of the respondents held only one ABC credential, the Certified Pedorthist credential, the remaining respondents held more than one ABC credential.

Table 1 Current ABC Credential(s) Held

C.Ped Only 79%C.Ped & Other ABC Credentials 21% Total 100%

As seen in Table 2, if respondents held other ABC credentials, they were most likely to hold the Certified Orthotist (CO) or Certified Fitter–Orthotists (CFO) credential. Two or more respondents held each of the remaining 11 other ABC credentials.

Table 2All Current ABC Credential(s) Held

Certified Pedorthist–C.Ped. 100%Certified Orthotist–CO 7%Certified Prosthetist–CP 1%Certified Prosthetist-Orthotist–CPO 2%Certified Fitter-orthotics–CFo 7%Certified Fitter-mastectomy–CFm 1%Certified Fitter-orthotics and mastectomy–CFom 1%Certified Fitter-therapeutic shoes–CFts 2%Registered Technician-Orthotic–RTO 1%Registered Technician-Prosthetic–RTP 0%Registered Technician-Prosthetic Orthotic–RTPO 0%Registered Orthotic Assistant–ROA 0%Registered Prosthetic Assistant–RPA 0%Registered Prosthetic Orthotic Assistant–RPOA 1%

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As seen in Table 3, about 56% of the sample of respondents were credentialed in the most recent six year period.

Table 3 Year Credentialed in Pedorthics

Before 1990 7%1990 - 1994 10%1995 - 1999 14%2000 - 2002 13%2003 - 2005 30%2006 - 2008 26%Total 100%

As seen in Table 4, about 47% of the respondents had 7 or less years of experience, while 19% of the respondents had 20 or more years of experience.

Table 4 Years of Experience in Pedorthic Practice

0 2%1 – 3 23%4 – 6 22%7 – 9 12%10 - 14 13%15 - 19 9%20 - 30 14%31+ 5%Total 100%

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In regard to the highest education degree/certificate/diploma earned in any discipline, 30% of the respondents had earned a baccalaureate degree, and 16% had earned a master’s degree or higher (see Table 5).

Table 5 Highest Educational Degree/Certificate/Diploma Earned in ANY Discipline

HS/GED 3%HS/GED and Pedorthic 120 hour course 26%HS/GED and Pedorthic CAPEapproved 3 Levels of Pedorthic Courses 6%AA/AS in O/P 3%AA/AS (non O/P) 9%BA/BS (non O/P) 30%BS in O/P 0%BA/BS and O/P post-baccalaureate certificate 4%Master’s Degree in O/P 0%Master’s Degree (non O/P) 10%Doctorate 6%Other 3%Total 100%

As seen in Table 6, respondents held a variety of other professional licenses or certifications. Examples of “other” include Doctors of Chiropractic and Registered Nurses.

Table 6Additional Healthcare Professional Licenses and/or Certifications Held

PT® (Physical Therapist) 8%PTA® (Physical Therapy Assistant) 4%OTR® (Occupational Therapist Registered) 2%COTA® (Certified Occupational Therapy Assistant) 1%CHT® (Certified Hand Therapist) 0%ATC® (Athletic Trainer Certified) 5%LAT® (Licensed Athletic Trainer) 0%PAC (Physician’s Assistant Certified) 0%DPM (Podiatrist) 7%BOC Pedorthist™ 32%BOCO™ 12%BOCP™ 4%BOC COF™ 7%BOC Footwear Specialist™ 2%Other 39%


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In describing their primary work setting, 25% of the Certified Pedorthists indicated that they work in a single-location retail setting, privately owed, and 14% indicated that they work in a single location pedorthic practice, privately owned (see Table 7). Fewer than 10% of the respondents worked in each of a wide variety of additional settings.

Table 7 Primary Work Setting

Single location retail setting – privately owned 25%Multi-facility retail setting – privately owned 9%Single location pedorthic practice – privately owned 14%Multi-facility pedorthic practice – privately owned 4%Single location orthotic and prosthetic practice – privately owned 4%Multi-facility orthotic and prosthetic practice – privately owned 9%Multi-facility orthotic and prosthetic practice – publically owned 3%Medical practice – privately owned 6%Hospital-based practice 6%DME/HME facility 7%Sport/athletic company 1%University-based practice 2%Central fabrication center/company 4%Other 6%Total 100%

In regard to the number of employees at the respondents’ primary work setting (excluding clerical employees), 91% of the respondents work with between one and five other employees (see Table 8).

Table 8 Total Number of Pedorthic Employees Located at Primary Work Setting

(Excluding Clerical Employees)

1 – 5 91%6 – 10 6%11 – 15 2%16 or more 1%

As documented in Table 9, respondents documented the percentage of their work time they spent in each of five areas. Respondents spend the most time in clinical pedorthic patient care (36%), about one fourth of their time in retail pedorthic services (20%), and somewhat less time in either administration (17%) or pedorthic fabrication (14%).


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Table 9 Primary Work Performed

Clinical pedorthic patient care (e.g., patient assessment, formulation of the treatment plan, implementation of pedorthic plan, follow-up patient care) 36% Retail pedorthic services (e.g., provision of non-prescription shoes, inserts) 20% Pedorthic fabrication 14% Continuing education 6% Administration (e.g., documentation, reimbursement, marketing, management) 17% Other 7%Total 100%

Respondents described the settings wherein they delivered direct patient care. As documented in Table 10, respondents spend the majority of their time in a pedorthic practice/clinic (74%). On average, respondents spent no more than 8% of their time in any other specifically-delineated practice setting.

Table 10 Percentage of Direct Patient Care That Occurred in Various Settings

Pedorthic practice/clinic 74% A specialty clinic (e.g., wound care, diabetic clinic) 8% An acute care hospital setting 4% A long-term-care facility (e.g., nursing home, assisted living facility) 5% A stand-alone rehabilitation facility 2% Patient’s home 3% Any other facility 4% Total 100%

The respondents described the patients to whom they delivered direct patient care. As documented in Table 11, nearly one half each of the patients were either adult patients (47%) or geriatric patients (45%). Only a few were pediatric patients (8%).

Table 11 Percentage of Patients in Following Age Ranges

Pediatric (0 - 18) 8%Adult (19 -65) 47% Geriatric (65+) 45% Total 100%


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As documented in Table 12, one half of the respondents’ patients present with diabetes (48%), and about one fourth of the patients present with either posterior tibial tendon dysfunction (12%) or arthritis (14%).

Table 12 Percentage of Patients in Each of the Following Primary Diagnostic Categories

Diabetes 48%Posterior Tibial Tendon Dysfunction 12%Arthritis 14%Trauma 8%Congenital 9%Plantar fasciitis 3%Sports related injury 2%Acquired foot disorders (e.g., biomechanical, pes planus, metatasalgia, heel spur, foot pain) 2%Other 2%Total 100%

Respondents were asked to further describe their diabetic patients. As seen in Table 13, the respondents’ diabetic patients were most likely to present with diabetes only (71%), and were far less likely to present with either diabetes with ulceration (18%) or diabetes with amputation (11%).

Table 13 Percentage of Diabetic Patients in Each of the Following Primary Diagnostic Categories

Diabetes only 71%Diabetes with ulceration 18%Diabetes with amputation 11%

Finally, respondents indicated that about 44% of their diabetic patients had significant peripheral neuropathy (see Table 14).

Table 14 Percentage of Diabetic Patients that had Significant Peripheral Neuropathy

Percentage of Diabetic Patients that had Significant Peripheral Neuropathy 44%


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Respondents were asked to provide a demographic description, including gender, age, and race/ethnic background. As shown in Table 15, Table 16, and Table 17, the overall sample responding to the survey was predominantly male, over the age of 35, and Caucasian/White (non-Hispanic). This demographic picture of the sample is consistent with the population of Certified Pedorthists in the ABC database.

Table 15 Gender of Respondents

Female 29%Male 71%Total 100%

Table 16 Age of Respondents

Under 25 1%25 – 34 13%35 – 44 24%45 – 54 35%55 – 64 22%65 or over 4%Total 100%

Table 17

Racial/Ethnic Background of Respondents

American Indian/Eskimo/Aleut 1%Asian or Pacific Islander 4%African American/Black 2%Caucasian/White (non-Hispanic) 87%Hispanic 4%Multiracial 1%Other 0%Total 100%


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Domains, Tasks, Knowledge and Skill Statements

Domains are global areas of responsibility performed by credentialed professionals; in the current delineation, the domains were defined as Patient Assessment, Formulation of the Treatment Plan, Implementation of the Treatment Plan, Follow-up Treatment Plan, Practice Management, and Promotion of Competency and Enhancement of Professional Practice.

Tasks are the activities performed within a domain in the course of practice; for example, Review patient’s prescription/referral in order to develop an appropriate diagnosis-specific assessment, is a task performed within the domain of Patient Assessment.

Knowledge and skill statements describe the organized body of information and the physical or mental manipulation of information or things required to perform the tasks associated with each domain; for example, Knowledge of clinical examination techniques, (e.g., range of motion (ROM), manual muscle tests, sensation, palpation), is knowledge required in association with the domain of Patient Assessment.

A layout of the final structure of the delineation specifying the number of tasks and knowledge and skills statements associated with each domain is contained in Table 18.

Table 18Certified Pedorthist Domains and Tasks

Domain Number of Tasks

Patient Assessment 8

Formulation of the Treatment Plan 8

Implementation of the Treatment Plan 16

Follow-up Treatment Plan 9

Practice Management 8

Promotion of Competency and Enhancement of Professional Practice 7

Total 56

87 knowledge and skill statements were developed for the Pedorthic Practice Analysis.

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Domains

Results and Discussion Related to the Domains

This section presents the results of the ratings related to the six domains of practice delineated in the survey. Respondents to the survey rated each of the domains on two ratings scales:

• Percentage of Time: Overall, what percentage of your work time did you spend performing the tasks related to each domain during the past year?

• Criticality: How critical is this domain to optimizing outcomes for patients, caregivers, and healthcare providers? 1=Not critical, 2=Minimally critical, 3=Moderately critical, or 4=Highly critical

Table 19 presents the results of the Percentage of Time and Criticality rating scale for the domains for the respondents including those who hold the Certified Pedorthist credential. As can be seen, respondents indicated that they spend the most time performing tasks associated with Patient Assessment, and the least time performing tasks associated with Promotion of Competency and Enhancement of Professional Practice.

Three domains, Patient Assessment, Formulation of the Treatment Plan, and Implementation of the Treatment Plan, were rated as highly critical to optimizing outcomes for patients, caregivers, and/or healthcare providers. The remaining three domains, Follow-up Treatment, Practice Management, and Promotion of Competence and Enhancement of Professional Practice, were rated as moderately to highly critical.

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1 Overall, what percentage of your work time did you spend performing the tasks related to each domain during the past year?2 How critical is this domain to optimizing outcomes for patients, caregivers, and health care providers?1 = Not critical, 2 = Minimally critical, 3 = Moderately critical, 4 = Highly critical.

Table 19 Descriptive Statistics for Domains

Mean for Percentage of Time and Criticality

% of Time1 Criticality2 Patient Assessment Perform a comprehensive assessment of the patient to obtain an understanding of the patient’s pedorthic needs. 28% 3.8

Formulation of the Treatment PlanAnalyze and integrate information from patient assessment to create a comprehensive pedorthic treatment plan tomeet the needs and goals of the patient. 16% 3.7

Implementation of the Treatment Plan Perform procedures necessary to provide the appropriate pedorthic services, including fabrication. 21% 3.7

Follow-up Treatment PlanProvide continuing patient care and periodic evaluation to assure/maintain/document optimal fit and function of the pedorthic device. 11% 3.5

Practice ManagementDevelop, implement, and/or monitor policies and procedures regarding human resources, the physical environment, business and financial practices, and organizational management. 11% 3.3

Promotion of Competency and Enhancement of Professional PracticeParticipate in personal and professional development through continuing education, training, research, and organizational affiliations. 9% 3.4

Other 4% 3.1


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Tasks

Results and Discussion Related to the Tasks

All survey respondents rated the tasks on two rating scales:

• Frequency:Howfrequentlydidyouperformthetaskduringthepastyear? 1=Never or rarely (quarterly), 2=Occasionally (monthly), 3=Frequently (weekly), or 4=Very frequently (daily)

• Criticality:Howcriticalisthetasktooptimizingoutcomesforpatients,caregivers,andhealthcareproviders? 1=Not critical, 2=Minimally critical, 3=Moderately critical, or 4=Highly critical

Table 20 displays the mean Frequency ratings for tasks for respondents. As can be seen, the Frequency ratings of all but six of the 41 tasks in the four patient care domains indicate that Certified Pedorthists perform these tasks frequently to very frequently. They perform the remaining four tasks in those same domains somewhat less frequently.

Certified Pedorthists perform the tasks associated with one of the two remaining domains (Practice Management) occasionally to frequently and the tasks associated with the remaining domain (Promotion of Competency and Enhancement of Professional Practice) somewhat less frequently. A review of those three tasks associated with lower frequency ratings indicates that these tasks do not readily lend themselves to frequent performance (e.g., Conduct and participate in evidence-based practice, clinical trials, outcome studies, product development, and research).

Without exception, the mean Criticality task ratings for the respondents holding the Certified Pedorthic credential indicated that these tasks are all moderately to very critical to optimizing outcomes for patients, caregivers, and/or healthcare providers.

In summary, the overall pattern of the Frequency and Criticality ratings on the tasks indicates that the practice analysis delineation included critical tasks performed by Certified Pedorthists. This pattern of Frequency and Criticality ratings validates the use of these tasks in initiatives related to examination development.


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Table 20 Task Statements

Means for Frequency and Criticality

Frequency1 Criticality2 Patient Assessment

Review patient’s prescription/referral in order to develop an appropriate diagnosis-specific assessment. 3.6 3.7

Take a comprehensive patient history, including chief complaint, diagnosis, medical history (including allergies to materials), results of diagnostic evaluations, work history, vocational activities, demographics characteristics, family and/or caregiver dynamics, reimbursement status, patient compliance, patient expectations. 3.4 3.6

Assess patient’s previous and current use of pedorthic devices and/or footwear and other devices (e.g. lower limb orthoses/prostheses) using systematic assessment procedures to determine current status and the efficacy of previous pedorthic intervention. 3.5 3.7

Assess the patient’s feet for deformities and disorders by performing a biomechanical evaluation; and assessing range of motion, alignment, muscle functioning/strength, and gait to assist in the development of the pedorthic treatment plan. 3.6 3.7

Evaluate the patient’s skin integrity, level of protective sensation, and circulatory status to establish the patient’s limitations for footwear. 3.3 3.6

Consult with primary and other healthcare providers, and caregivers, when appropriate, about patient’s condition in order to formulate a treatment plan. 3.0 3.5

Verify patient care by documenting history, ongoing care, and follow-up, using established record-keeping techniques. 3.6 3.7

Refer patient, if appropriate, to other healthcare providers for intervention beyond pedorthic scope of practice. 2.9 3.6

Formulation of the Treatment Plan

Evaluate the assessment findings to formulate a pedorthic treatment plan. 3.5 3.7

Formulate treatment goals and expected pedorthic outcomes to prevent injury, reduce pain, increase comfort, provide stability, reduce risk of deformity, prevent disability, and promote healing to enhance function and independence. 3.5 3.8

Develop an appropriate pedorthic treatment plan using assessment data to provide optimal patient care, including education and follow-up. 3.4 3.7

Identify design, materials, and components to support treatment plan. 3.5 3.7

1 Frequency—Howfrequentlydidyouperformthetaskduringthepastyear? 1 = Never or rarely (quarterly), 2 = Occasionally (monthly), 3 = Frequently (weekly), 4 = Routinely (daily). 2 Criticality—Howcriticalisthistasktooptimizingoutcomesforpatients,caregivers,andhealthcareproviders? 1 = Not critical, 2 = Minimally critical, 3 = Moderately critical, 4 = Highly critical.


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Consult with physician/referral source/appropriately licensed healthcare provider to modify, if necessary, the original prescription and/or treatment plan. 2.7 3.6

Communicate with patient and/or caregiver about the recommended treatment plan and any optional plans, including disclosure of potential risks/benefits in pedorthic care. 3.4 3.7

Document treatment plan using established record-keeping techniques. 3.5 3.6

Ensure that patient or responsible parties are informed of their financial responsibilities pertaining to the proposed treatment plan (for example, insurance verification/authorization, deductibles, co-pays). 3.4 3.6

Implementation of the Treatment Plan

Inform patient and/or caregiver of the pedorthic procedure, potential risks, and time involved in the procedure. 3.4 3.7

Select the appropriate footwear and/or pedorthic device(s), and materials consistent with the patient’s condition to maximize the effectiveness of pedorthic treatment. 3.7 3.8

Refer to manufacturer’s specifications and other technical resources regarding components/materials. 2.7 3.1

Measure/fit shoes using assessment data to maximize the effectiveness of pedorthic treatment. 3.5 3.8

Measure/fit prescription and non-prescription compression garments and diabetic socks/hosiery using assessment data to maximize the effectiveness of pedorthic treatment. 2.2 3.0

For custom-molded foot orthoses and/or partial foot prostheses, obtain a negative foot impression using appropriate casting or computer-assisted techniques to fabricate the device. 3.4 3.7

For custom shoes, obtain a negative model of the patient’s foot using appropriate casting or computer-assisted techniques to specify fabrication requirements. 2.4 3.5

Prepare and modify patient model/image for fabrication. 2.8 3.5

Fabricate foot orthoses and partial foot shoe inserts using assessment data to implement the pedorthic treatment plan. 3.0 3.6

Modify footwear, when required, to implement the pedorthic treatment plan. 3.0 3.6

Assess device prior to patient fitting/delivery for structural safety and ensure that manufacturers’ guidelines have been followed. 3.4 3.6

Ensure that materials, design, and components are provided as specified in the treatment plan. 3.5 3.7

Frequency1 Criticality2


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Conduct fittings of a pedorthic device(s), making adjustments as needed, to ensure proper fit and function. 3.5 3.7

Provide the patient and/or caregiver with oral and written instructions on the proper use and care of pedorthic device(s). 3.5 3.8

Document treatment using established record-keeping techniques to verify implementation of treatment plan. 3.6 3.8

Refer patient and/or caregiver to appropriate healthcare providers for necessary ancillary care. 3.0 3.6

Follow-up Treatment Plan

Obtain feedback from patient and/or caregiver to evaluate outcome (e.g., wear schedule/tolerance, comfort, perceived benefits, perceived detriments, ability to don and doff, proper usage and function, overall patient satisfaction). 3.4 3.6

Assess and document patient’s function, efficacy of pedorthic device(s), and achievement of treatment goals. 3.3 3.6

Assess patient’s skin condition (e.g., integrity, sensation, color, temperature, and volume) and note any changes. 3.1 3.6

Assess fit of pedorthic device(s) with regard to anatomical relationships (for example, trimlines, strategic contact, static/dynamic assessment) to determine need for changes relative to initial treatment goals. 3.4 3.7

Make or supervise modifications to pedorthic device(s) (for example, relieve pressure, change range of motion, alignment, and/or components) and inform patient and/or caregiver of changes. 3.4 3.7

Evaluate results of modifications and assess modified device(s) for structural integrity. 3.4 3.6

Reassess patient’s and/or caregiver’s knowledge of goals and objectives to ensure proper use of pedorthic device(s) relative to modifications. 3.2 3.6

Document all findings and pedorthic interventions and communicate, as necessary, with physicians, referral sources, and other healthcare providers to ensure patient status is updated. 3.3 3.5

Develop a long-term follow-up plan. 3.0 3.4

Practice Management

Comply with universal precaution procedures, occupational safety and health rules, and disability accommodation guidelines to protect patients and employees. 3.5 3.7



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Plan, implement, evaluate, document policies and procedures in compliance with all applicable federal and state laws and regulations and professional and ethical guidelines (e.g., CMS, HIPPA, FDA, ADA, OSHA, ABC Code of Professional Responsibility). 3.3 3.6

Develop, document, and implement personnel policies and procedures (e.g., benefits, training, incentives, staff recognition, regular performance evaluations). 2.7 3.3

Ensure an appropriate environment for patient care by maintaining adequate inventory, equipment, and supplies to provide pedorthic services in a professional and timely manner. 3.5 3.6

Develop, document, and implement a quality assurance plan in order to track deficiencies in current operations and improve overall pedorthic care by reviewing outcomes and addressing complaints from patients, payment sources, and/or referral sources. 2.9 3.4

Develop, document, and implement procedures for patient care that comply with current medical and legal requirements. 3.1 3.5

Develop and implement procedures for comprehensive documentation of patient care. 3.1 3.5

Operate the pedorthic practice in accordance with sound business principles and governmental requirements. 3.7 3.8

Promotion of Competency and Enhancement of Professional Practice

Participate in continuing education. 2.8 3.6

Provide education for pedorthists and other health care providers (for example, podiatrists, physical therapists, and orthopedists). 2.3 3.3

Participate in education of students and trainees. 2.1 3.2

Conduct and participate in evidence-based practice, clinical trials, outcome studies, product development, and research. 1.7 3.0

Participate in/with consumer organizations and nongovernmental organizations to promote competency, enhancement, and awareness of the pedorthic profession. 2.0 3.3

Promote a collaborative working relationship with other health care providers to enhance their understanding of the pedorthic scope of practice. 2.8 3.4

Participate in the development, implementation, and monitoring of public policy regarding pedorthics (e.g., provide testimony/information to legislative/regulatory bodies, serve on professional committees and regulatory agencies). 1.9 3.2



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Knowledge and Skill Statements

All survey respondents rated the 87 knowledge and skills statements on two rating scales:

• Criticality: How critical is this knowledge or skill to optimizing outcomes for patients, caregivers, and health care providers?

With only six exceptions, these knowledge and skills were rated as moderately to highly critical to optimizing outcomes for patients, caregivers, and/or healthcare providers. The ratings for the remaining six statements indicate that they all make at least a minimal to moderate contribution to optimizing outcomes.

• Acquisition: At what point should this knowledge or skill be acquired by a Certified Practitioner?

A majority of respondents supported the acquisition of 75 of the 87 knowledge and skills primarily before passing the ABC examination.

Table 21


Knowledge of musculoskeletal anatomy

Knowledge of basic neuroanatomy

Knowledge of basic neurophysiology

Knowledge of anatomical landmarks (surface anatomy)

Knowledge of basic kinesiology

Knowledge of basic pathokinesiology

Knowledge of normal human locomotion

Knowledge of gait training

Knowledge of pathological gait

Knowledge of tissue characteristics/management

Knowledge of volumetric control

Knowledge of planes of motion

Knowledge of biomechanics

Knowledge of pathomechanics


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Knowledge of pathologies

Knowledge of basic pharmacology

Knowledge of medical terminology

Knowledge of pedorthic terminology

Knowledge of referral documents

Knowledge of data recording procedures

Knowledge of policies and procedures regarding privileged information

Knowledge of roles and responsibilities associated with other healthcare professions

Knowledge of reimbursement protocols

Knowledge of material safety procedures and standards (e.g., OSHA, MSDS)

Knowledge of universal precautions, including sterile techniques and infection control

Knowledge of ethical standards regarding proper patient management, including ABC Code of Professional Responsibility

Knowledge of scope of practice related to pedorthic credentials

Knowledge of the extent and limitations of the scope of pedorthic practice (i.e., when to refer a patient to other healthcare providers/caregivers)

Knowledge of pedorthic design

Knowledge of shoe anatomy and construction

Knowledge of properties of various footwear styles, modifications, and designs

Knowledge of specific points of shoe fit

Knowledge of normal and abnormal wear patterns of footwear and other pedorthic devices

Knowledge of therapeutic and protective characteristics and features of various types of hosiery

Knowledge of pedorthic fitting criteria

Knowledge of clinical examination techniques, (e.g., range of motion (ROM), manual muscle tests, sensation, palpation)

Knowledge of impression-taking techniques, materials, devices, and equipment



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Knowledge of rectification/modification procedures as they relate to specific pedorthic designs

Knowledge of pedorthic measurement tools and techniques

Knowledge of pedorthic forms (e.g., assessment, orthometry, measurement, evaluation, outcomes)

Knowledge of properties of pedorthic materials

Knowledge of componentry

Knowledge of alignment devices and techniques

Knowledge of hand and power tools

Knowledge of mechanics (e.g., levers and force systems)

Knowledge of theory and application of intrinsic and extrinsic posting

Knowledge of internal and external shoe modifications and their purpose

Knowledge of care and maintenance of pedorthic devices

Knowledge of computer-aided design and manufacturing (CAD/CAM)

Knowledge of item warranty and warranty limitations

Knowledge of loss control (e.g., risk management, inventory control)

Knowledge of professional liability insurance requirements

Knowledge of research methodology and literature

Knowledge of human development and aging, ranging from pediatric to geriatric, as they relate to pedorthic treatment

Knowledge of patient compliance issues

Knowledge of the psychology of the disabled

Knowledge of patient educational materials

Knowledge of federal and state rules, regulations, and guidelines (e.g., FDA, ADA, HIPPA)

Knowledge of ABC Facility Accreditation Standards

Skill in interpreting referral documents, (e.g., prescriptions, orders)

Skill in interpreting radiological images

Skill in communicating with patient/family/caregiver



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Skill in communicating with referral sources and appropriately licensed healthcare providers

Skill in performing physical examinations

Skill in identifying gross surface anatomy

Skill in interpretation of physical findings (e.g., recognizing skin pressures, dermatological conditions, osseous deformity)

Skill in analysis of normal gait/motion

Skill in analysis of pathological gait/motion

Skill in interpreting wear patterns

Skill in managing patients relative to their diagnosis or condition

Skill in impression-taking/measuring for pedorthic device(s)

Skill in using mechanical measuring devices

Skill in using electrical measuring devices

Skill in using computer-based measuring devices

Skill in patient delineation, rectification, and/or modification of patient model

Skill in pedorthic fabrication

Skill in use of safety equipment

Skill in using hand and power tools

Skill in use of materials and components

Skill in use of alignment devices

Skill in aesthetic finishing

Skill in evaluating fit and function of pedorthic device(s)

Skill in adjusting and modifying pedorthic device(s)

Skill in maintaining and repairing pedorthic device(s)

Skill in restoring optimal fit and function of pedorthic device(s)

Skill in solving patient’s problems related to ADL

Skill in documentation


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Sect

ion

Thre

e

Results and Discussion Related to Orthotic and Pedorthic Devices

All survey respondents were asked to characterize the nature of their work in regard to an extensive list of orthotic and pedorthic devices. Respondents were asked to indicate each prescription-based pedorthic activity they performed independently (meaning no supervision was required.)

Respondents were asked to document the percentage of time they spend in various practice areas, including footwear, orthoses, pre-fabricated inserts, shoe modifications, and retail (no prescription, no medical condition). Table 22 presents time allocations for the respondents. Respondents indicated that they spend the most time with orthoses (41%) and footwear (30%), and less time in the remaining three areas.

Table 23 documents the percent of respondents performing various activities in regard to specific devices. Respondents are most likely to perform initial assessments, measure/mold/digitize/scan, fit, and/or perform follow-up/evaluation for the 26 devices listed. They are less likely to fabricate or modify these devices. Table 23 does not describe the percentage of time the Certified Pedorthist spends providing the device, it describes the breakdown of activities in which the C.Ped. participates in for each device.

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Table 22 Percentage of Time in Practice Areas with Regard to Devices

Practice Area Area Device 1. Footwear 30% 1.1 Therapeutic/Diabetic Shoes 16%1.2 In-depth Shoes (non-diabetic) 5%1.3 Custom Shoes 3%1.4 Pediatric Corrective Footwear 1%1.5 Athletic Shoes 4%1.6 Other 1%2. Orthoses 41% 2.1 Accommodative Foot Orthoses 13%2.2 Functional Foot Orthoses 15%2.3 UCBL Orthoses 2%2.4 Gait plates 1%2.5 Toe Filler Foot Orthoses 2%2.6 Custom Fabricated SCFO (Leather ankle gauntlet) 1%2.7 Dorsi-assist Orthoses (Pre-fabricated Night-time) 1%2.8 Dorsi-assist Orthoses (Pre-fabricated) 0%2.9 Dorsi-assist Orthoses (Custom fabricated) 1%2.10 Custom Fabricated Solid Ankle AFO 2%2.11 Custom Fabricated Articulated AFO 1%2.12 CROW Orthoses (Neuropathic Walking Orthosis) 1%2.13 Pre-fabricated fixed ankle walking boot (Cast walker) 1%2.14 Other 0%3. Pre-fabricated Inserts 11% 3.1 Pre-fabricated Accommodative Foot Orthoses 8%3.2 Pre-fabricated Rigid Foot Orthoses 3%3.3 Other 0%4. Shoe Modifications 9% 4.1 Shoe modifications (sole) 6%4.2 Shoe modifications (other) 3%4.3 Other 0%5. Retail: (no prescription, no medical condition) 9% 5.1 In-depth Shoes 3%5.2 Athletic Shoes 3%5.3 Pre-fabricated Accommodative Foot Orthoses 1%5.4 Pre-fabricated Rigid Foot Orthoses 1%5.5 Other 1%


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Table 23 Breakdown of Activities Performed by Certified Pedorthists Within Each Device Type

Perform Measure/ Modify Fabricate Fit Perform Initial Mold/ Follow-up/ Assessment Digitize Evaluation Scan Footwear Therapeutic/Diabetic Shoes 94% 90% 78% N/A 96% 92%In-depth Shoes 95% 87% 76% N/A 93% 89%Custom Shoes 94% 88% 67% 25% 91% 92%Pediatric Corrective Footwear 92% 86% 71% N/A 90% 89%Athletic Shoes 94% 80% 67% N/A 91% 83%Orthoses Accommodative Foot Orthoses 94% 91% 85% 65% 94% 91%Functional Foot Orthoses 93% 91% 83% 63% 92% 91%UCBL Orthoses 91% 89% 81% 62% 92% 91%Gait plates 90% 82% 73% 56% 86% 89%Partial Foot Shoe Insert 93% 92% 81% 66% 92% 92%Custom Fabricated SCFO (Leather ankle gauntlet) 89% 89% 64% 30% 89% 89%Dorsi-assist Orthoses (Pre-fabricated night-time) 93% 83% 56% 20% 92% 86%Dorsi-assist Orthoses (Pre-fabricated) 94% 81% 66% 22% 92% 88%Dorsi-assist Orthoses (Custom fabricated) 91% 90% 78% 48% 92% 92%Custom Fabricated Solid Ankle AFO 86% 84% 70% 42% 89% 86%Custom Fabricated Articulated AFO 86% 84% 70% 41% 87% 88%CROW Orthoses (Neuropathic Walking Orthosis) 92% 90% 73% 38% 88% 89%Pre-fabricated fixed ankle walking boot (Cast walker) 91% 81% 64% N/A 92% 86%Inserts Pre-fabricated Accommodative Foot Orthoses 94% 84% 75% N/A 94% 85%Pre-fabricated Rigid Foot Orthoses 93% 84% 77% N/A 93% 88%Modifications Shoe modifications (sole) 91% 73% 78% 61% 85% 88%Shoe modifications (other) 93% 75% 82% 61% 88% 88%Retail (no prescription, no medical condition) In-depth Shoes 95% 85% 61% N/A 94% 80%Athletic Shoes 94% 82% 57% N/A 93% 79%Pre-fabricated Accommodative Foot Orthoses 94% 84% 68% N/A 93% 81%Pre-fabricated Rigid Foot Orthoses 93% 84% 70% N/A 92% 84%


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Finally, respondents were asked specific follow-up questions. Respondents spending time on custom foot orthoseswereaskedtodocumentthepercentageineachofthefollowing—handcasted,impressionfoam,digitized/scanned, and other. Respondents indicated that the majority of their custom foot orthoses were impression foam (61%), rather than either hand casted (25%) or digitized/scanned (11%). See Table 24.

Table 24 Percentage of Custom Foot Orthoses by Category

% Hand casted 25%Impression foam 61%Digitized/scanned 11%Other 3%

In regard to the use of computer-aided design and manufacturing (CAD/CAM), respondents indicated that they incorporate CAD/CAM while providing custom pedorthic devices 18% of the time. See Table 25.

Table 25 Percentage of the Custom Pedorthic Devices Provided for Patients Incorporating

the Use of Computer-Aided Design and Manufacturing (CAD/CAM)

% Pedorthic Devices Utilizing CAD/CAM 18.6%

Respondents were nearly twice as likely to fabricate custom foot orthoses onsite than to outsource them (see Table 26).

Table 26 Percentage of All Custom Foot Orthoses Fabricated Onsite or Outsourced

% Onsite 65% Outsourced 34%

Respondents were more likely to outsource the fabrication of custom AFO’s than to fabricate them onsite (see Table 27).

Table 27 Percentage of All Custom AFO’s Fabricated Onsite or Outsourced

% Onsite 48%Outsourced 52%


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Highlights Related to Professional Background, Work Setting and Demographic Information

• MorethanthreefourthsoftherespondentsheldonlytheABCCertifiedPedorthistcredential.Ifthey held any other ABC-related credential, it was most likely the Certified Orthotist (CO) or Certified Fitter–orthotics credential (CFo).

• Sixtypercentoftherespondentsindicatedthattheirinitialqualifyingeducationaldegree/certificate/diploma for the Certified Pedorthist credential was a HS/GED and 120 hour pedorthic course.

• Indescribingtheirprimaryworksetting,25%oftheCertifiedPedorthistsindicatedthattheyworkin a single-location retail setting, privately owed, and 14% indicated that they work in a single location pedorthic practice, privately owned.

• Respondentsspendthemosttimeinclinicalpedorthicpatientcare(36%).Respondentsonlyspendabout one fourth of their time in retail pedorthic services (20%), and somewhat less time in either administration (17%) or pedorthic fabrication (14%).

• Respondentsdescribedthepatientstowhomtheydelivereddirectpatientcare.Nearlyonehalfeach of the patients were either adult patients (47%) or geriatric patients (45%). Only a few were pediatric patients (8%). About one half of the respondents’ patients present with diabetes (48%), and about one fourth of the patients present with either posterior tibial tendon dysfunction (12%) or arthritis (14%).

• Theoverallsamplerespondingtothesurveywaspredominantlymale,overtheageof35,andCaucasian/White (non-Hispanic). This demographic picture of the sample is quite consistent with the population of Certified Pedorthists in the ABC database.

Highlights Related to Domains, Tasks, Knowledge and Skills, and Pedorthic and Orthotic Devices

• RespondentsindicatedthattheyspendthemosttimeperformingtasksassociatedwithPatientAssessment, and the least time performing tasks associated with Promotion of Competency and Enhancement of Professional Practice. Three domains, Patient Assessment, Formulation of the Treatment Plan, and Implementation of the Treatment Plan, were rated as highly critical to optimizing outcomes for patients, caregivers, and/or healthcare providers. The remaining three domains, Follow-up Treatment Plan, Practice Management, and Promotion of Competency and Enhancement of Professional Practice, were rated as moderately to highly critical.

• TheFrequencyratingsofallbutsixofthe41tasksinthefourpatientcaredomainsindicatethatCertified Pedorthists perform these tasks frequently to very frequently. They perform the remaining four tasks in those same domains somewhat less frequently.


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• Withoutexception,themeanoftheCriticalitytaskratingsfortherespondentsindicatedthatthesetasks are all moderately-to-very critical to optimizing outcomes for patients, caregivers, and/or healthcare providers.

• TheoverallpatternoftheFrequencyandCriticalityratingsonthetasksindicatesthatthepracticeanalysis delineation included critical tasks performed by Certified Pedorthists. This pattern of Frequency and Criticality ratings validates the use of these tasks in initiatives related to examination development.

• Withonlysixexceptions,the87knowledgeandskillswereratedasmoderatelytohighlycriticalto optimizing outcomes for patients, caregivers, and/or healthcare providers. The ratings for the remaining six statements indicate that they all make at least a minimal to moderate contribution to optimizing outcomes.

• Amajorityofrespondentssupportedtheacquisitionof75ofthe87knowledgeandskillsprimarilybefore taking the ABC examination.

• TheoverallpatternoftheCriticalityandPointofAcquisitionratingsontheknowledgeandskillsindicates that the practice analysis delineation included critical knowledge and skills required by Certified Pedorthists. The ratings validate the use of these tasks in initiatives related to examination development.

• Respondentswereaskedtodocumentthepercentageoftimetheyspentinvariouspracticeareas,including footwear, orthoses, pre-fabricated inserts, shoe modifications, and retail (no prescription, no medical condition). Respondents indicated that they spend the most time with orthoses (41%) and footwear (30%), and less time in the remaining three areas.

• Respondentsaremostlikelytoperforminitialassessments,measure/mold/digitize/scan,fit,and/or perform follow-up/evaluation for the 26 devices identified. They are less likely to fabricate or modify the devices.

• Respondentsindicatedthatthemajorityoftheircustomfootorthoseswereimpressionfoam(61%),rather than either hand casted (25%) or digitized/scanned (11%).

• Respondentswerenearlytwiceaslikelytofabricatecustomfootorthosesonsite(65%)thantooutsource them (34%).

• InthecaseofcustomAFOs,respondentswereslightlymorelikelytooutsourcefabrication(52%)than to fabricate onsite (48%).


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Highlight of Results Related to Qualitative Comments

Respondents were asked to describe the knowledge and/or skills they had acquired during the past year. About 50% of the respondents answered this open-ended question, indicating a broad focus on new learning. Five or more of the respondents had indicated that they had acquired each of the following knowledge and/or skills sets during the past year:

• biomechanics

• billingandreimbursementsissues

• businessmanagementandmarketing

• castingtechniques

• CAD/CAM

• computerskills

• dermatologicalissuesandwoundcare

• diabetes-relatedcare

• fabricationtechniques

When asked to “describe the benefits you have received as a result of obtaining your ABC credential,” the respondents provided extremely positive comments. The most frequent response was related to enhanced recognition followed by an appreciation of the knowledge that the credential signified. Respondents were also likely to describe enhanced opportunities, personal fulfillment, and salary and wage increases. The following comments are representative of the positive feelings of the majority of the survey respondents.

• ABCcredentialingaddscredibilitytoourpracticeandenhancespublicimageandgaveusacriticallook at the way we conduct our business and helped us to become better providers and pedorthists.

• Afterover30yearsasaC.Ped,Idon’tknowofanyprofessionthatimmediatelyenhancesthequality of life of the patient as pedorthics can. Thank you for changing my life is heard almost daily in our profession.

• BeingapartoftheGoldStandard.

• Comfortinbeingpartofabiggerorganization,andbeingateammemberofthehealthcarefieldinworking with patients who need biomechanical assistance.

• AsanRPOAandCFowith16yearsexperienceIhaveagoodjobinastablefield.AsaC.PedIhave a credential that I can use independently in licensure states if I wish to go out on my own.


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• WithourC.Ped.credential,physicianscannowbeassuredthatthepatientstheyrefertoourpractice are getting professional, appropriate care. This means we get many more referrals and are extending our links into the medical community. At the same time, it separates us dramatically from other sports retailers in the area because we have without question the most educated, specialized staff available in our region.

• IhavebeenrecognizedinmyareabylocalPodiatristandotherDoctorsonthefootwearandmodifications I can perform for their patients.

• Ihavetheconfidencethatmyknowledge,skilllevelandexperienceinthefieldoforthoticsandpedorthics make me a worthy practitioner in this field.

• I’dworkedinthefieldundermyPodiatristfor8yearsandsincebecomingaC.Ped.Ihavemoreknowledge and can handle most situations by myself. My referral sources appreciate that they have someone who cares about their patients like they do. My salary has increased and the care that I give to our patients is rewarding.


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Alexandria, VA 22314703.836.7114

www.abcop.org

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